Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form A Page 1 of 2

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
this number will not result in the denial of any right, benefit, or privilege to which you may be entitled.

Instructions on Completing this Form:

You should use this petition form only if NIOSH has reported to you in writing that it cannot complete the
dose reconstruction needed for your cancer claim.

All other petitioners should use Petition Form B to submit a petition to NIOSH.

For Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Division of Compensation Analysis and
Support about an SEC petition: 1-877-222-8570.

A NIOSH Claim Information — Complete as much information as you can in Section A.

Ad NIOSH Tracking Number (indicated on all NIOSH correspondence):

A.2 Print Name of Enerav Emplovee for whom this claim was filed:

First Name Middle Initial Last Name

A.3. Social Security Number of Energy Employee for whom this claim was filed:

Signature of Person Submitting this Petition — Complete Section B.

Print and sign your name below to indicate that you are petitioning for HHS to consider adding a class
of employees to the Special Exposure Cohort that would include the employee indicated by the
tracking number or name under entry 1 above:

Print vour name below: Sign your name below:
First Name Middle Initial Last Name First Name Middle Initial Last Name
c Please send this form to NIOSH at the address below.
Once NIOSH receives this form, the U.S. Department of Health and Human Services i! ideFadding a
class of employees to the Special Exposure Cohort. Your contact at NIOSH will be arm you of
the progress of your petition. R
Send this form to: SEC Petition
Division of Compensation Analysis and Support
NIOSH

4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

Name or Social Security Number of First Petitioner:



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Program Act National Institute for Occupational Safety and Health

‘ a & fs, OMB Number: 0920-0639 Expires: 07/31/2016
Petitioner Authorization Form Page 1 of 2

Use of this form is voluntary. Failure to use this form will not result in
the denial of any right, benefit, or privilege to which you may be entitled.

Instructions:

If you wish to petition HHS to consider adding a class of energy employees to the Special Exposure Cohort
and you are NOT either a member of that class, a survivor of a member of that class, or a labor organization
representing or having represented members of that class, then 42 CFR Part 83, Section 83.7(c) requires
that you obtain written authorization. You can obtain such authorization from either an energy employee who
is a member of the class or a survivor of such an employee. You may use this form to obtain such

| authorization and submit the completed form to NIOSH with the related petition. Please print legibly.

For Further Information: If you have questions about these instructions, please call the following
NIOSH toll-free phone number and request to speak to someone in the Division of Compensation
Analysis and Support about an SEC petition: 1-877-222-8570.

Name of Class Member or Survivor

Street Address of Class Member or Survivor Apt. # P.O. Box

City, State, Zip Code of Class Member or Survivor

do hereby authorize:

Name of Petitioner

Address of Petitioner Apt. # P.O. Box

| City, State and Zip Code of Petitioner

In providing this authorization, | recognize that the petitioner named above will have all'the rights
of a petitioner as provided for under 42 CFR Part 83. .

Signature of Class Member or Survivor Date “



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Occupational Safety & Health UNITED STATES

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